Daniel Futers

St. Nicholas Hospital 
Jubilee Road  
Gosforth 
Newcastle upon Tyne  
NE3 3XT 

Derek Winter  
HM Senior Coroner for Sunderland 
The Coroner’s Office Civic Centre  
Burdon Rd  
Sunderland  
SR2 7DN 

Dear Sir 

Inquest into the death of Daniel Futers  
Regulation 28 Report to Prevent Future Deaths Response 

We write in response to your Regulation 28 Report dated 2 February 2023 following 
your investigation into the death of Daniel Futers.  

The  Trust  was extremely  disappointed  to  receive  this  Regulation 28  Report.  As  HM 
Coroner  is  aware,  the  Trust  takes  all  patient  deaths  very  seriously  and  investigates 
them  rigorously to establish if lessons can be learned or services can be improved 
and  this  case  was  no  exception.  It  is  noted  however,  that  this  investigation  did  not 
identify  any  issues  with  the  care  provided  to  Daniel  and/or  any  issues  in  relation  to 
compliance  with  Trust  policies/procedures,  save  for  in  relation  to an  issue  identified 
whereby Daniel’s belongings went missing whilst he was on leave. Following receipt 
of  the  Inquest  outcome,  the  Trust  has  carried  out  a  further  review  of  the  serious 
incident  investigation  report  findings  and  has  not  identified  any  omissions  of  key 
evidence or additional learning points.  

For the purposes of responding to your specific concerns raised in the Regulation 28 
Report, I shall address each of them in turn: 

1.  The  recording  of  information,  particularly  that  conveyed,  was  not  as 
comprehensive  as  it  ought  to  have  been.  For  example,  a  record  of  an 
altercation had not been made. 

As presented at the inquest:- 

a.  The  expectation  of  the  Trust  is  that  all  contact  with  a  patient  and/or 
carer/family member is documented in the patient’s electronic care records. 
There is no reason to believe that this did not occur in this matter and HM 
Coroner did not hear any evidence from the Trust that there were any  

 
 
  
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
     
 
 
 
 
 issues  in  the  recording  and  documenting  of  information  provided  to  those 
involved in Daniel’s care.  

b.  A  number  of  contacts  were  made  by  Daniel  and/or  his  mum  to  the  ward 
between 29 March and 3 April 2022 advising that Daniel was ‘bored’ and / 
or  ‘anxious’.  Assurances  and  advice  was  provided  by  ward  staff  on  each 
occasion  as  well  as  consultation  with  the  on-call  Consultant  where 
appropriate.  In  this  period,  Daniel  was  also  reviewed  by 
  on  30 
March  2022  and  again  by  3  members  of  nursing  staff  when  his  depot 
medication  was  administered  on  2  April  2022.  All  of  the  above  contacts 
were  documented  in  Daniel’s  progress  notes  including  documentation  to 
confirm  that  the  above  concerns  had  been  reviewed  appropriately  by  the 
on-call Consultant.  

c.  No concerns were raised by Daniel’s family or Daniel on either 4 or 5 April 
2022. However, it is noted in the statement submitted by Daniel’s mum that 
she had a number of concerns over and above Daniel being anxious and 
bored whilst he was on leave including him ‘standing guard’ over her while 
she  was  sleeping,  asking  about  ‘fast  forwarding  his  life’,  talking  about 
government  conspiracies  and  Daniel  generally  displaying  paranoid 
behaviour.  It  is  also  noted  in  this  statement  however,  that  Daniel’s  mum 
‘did not have much communication with staff but had written an extensive 
list of…concerns…which I intended to raise whilst we were there and face 
to  face…’  Had  this  information  been  fed  back  to  the  Ward,  the  clinicians 
could  have  reviewed  and  acted  upon  the  information  appropriately.  It  is 
therefore  entirely  unfair  and  disproportionate  to  criticise  the  Trust  for  its 
recording  of  information,  or  alleged  lack  thereof,  when  such  information 
was not reported.  

d.  In  respect  of  the  altercation  referred  to  by  Daniel’s  mum  in  which  it  is 
alleged  that  Daniel  broke  his  phone  whilst  on  the  ward,  the  entry  in  the 
progress  notes  from  29  March  2022  is  detailed  and,  most  importantly, 
contemporaneous. That it does not accord with Daniel’s mum’s recollection 
of the call as expressed during the inquest is not in itself a reflection of a 
fundamental issue with Trust recording of notes.  

2.  Comprehensive  planning  for  home  leave  and  discharge  from  hospital  was 
not  evident,  including  contingency  planning  and  the  involvement  of  the 
family.  

The evidence at the inquest confirmed the following: -  

a)  Daniel was acutely unwell when he arrived at Hopewood Park hospital on 22 
February  2022  and  was  detained  under  s.2  MHA  however,  he  made  a 
‘remarkable’  (but  not  unusual)  recovery  once  his  depot  medication  had  been 
commenced. This was entirely in line with his previous pattern (‘nature’ with  

 
 
  
  
 
 
 
 
 
 
 
 
 
 
 reference  to  the  terminology  of  the  MHA)  of  recovery  and  it  was  clinically 
appropriate for professionals to rely on previous history as an indicator of how 
Daniel’s illness may progress.   

b)  Daniel was assessed on 22 March 2022 by 

 and a Nurse 
practitioner  and  it  was  felt  that  Daniel  had  considerably  improved  and  was 
insightful as to the need for treatment. The plan following this assessment was 
to continue with his depot medication and to trial section.17 leave starting with 
escorted leave.  

c)  S.17  leave  was  part  of  Daniel’s  treatment  plan  and  the  intention  was  to 
progress leave gradually i.e. starting with escorted leave for a short period of 
time and leading up to an extended period of unescorted leave. This is in line 
with expected practice and was appropriate in terms of balancing risks, clinical 
need  and  testing  the  response  to  treatment  in  order  to  safely  work  towards 
discharge. 

d)  The  intention  of  s.17  leave  is  to  provide  patients  with  independence  to 
manage  in  the  community  and  to  avoid  patients  becoming  institutionalised 
and/or reliant on mental health services. In the vast majority of cases, it will be 
a fundamental part of the treatment plan. Daniel was no exception to this.   

e) 

  confirmed  that  Daniel  was  asked  during  every  assessment  whether 
he  had  any  stressors  and  he  denied  this  at  each  assessment.  Dr  Chan 
confirmed that  Daniel was  looking  forward  to  the  future, getting back  to  work 
and  the  gym  and  building  a  life  in  the  community.  In  addition  to  what  Daniel 
  was  assured  objectively  by  Daniel’s 
was  verbally  reporting, 
presentation,  demeanour  and  reported  observations  of  him  on  the  ward  and 
assured that he was recovering.  

f) 

  considered  that  Daniel’s  leave  was  going  well and  although  he  was 
aware  of  reports  regarding  ‘boredom’  and  some  ‘anxiety’,  there  were  no 
concerns  highlighted  either  subjectively  or  objectively  which  would  have 
warranted Daniel to be recalled to hospital.  

g)  Daniel  had  been  assessed  as  low  risk  of  self-harm  and  it  appeared  that  he 
only self-harmed when he was acutely unwell (with the last known self-harm / 
suicide  attempt  having  been  in  2014  immediately  prior  to  a  hospital 
admission).  Daniel  was  not  acutely  unwell  at  the  time  the  leave  was 
authorised. 
  confirmed  that  the  fact  that  Daniel  had  been  so 
responsive  to  the  depot  medication  was  a  protective  factor  whilst  he  was  on 
  confirmed  that  Daniel’s  further  protective  factors  were  future 
leave. 
planning, his family and a community treatment plan (whereby Daniel’s depot 
would be administered by the Community Treatment Team).   

h) 

  confirmed  that  the  key  risk  factor  for  Daniel  in  the  community  was 
illicit drug use although Daniel confirmed that he had not recently being taking  

 
 
  
  
 
 
 
 
 
 
 
 
 
 
 illicit drugs.  

i) 

  confirmed  that  Daniel  had  had  previous  admissions  to  hospital 
whereby Daniel had only been admitted for a short period of time prior to being 
discharged from his section.  

j) 

k) 

  advised  that  boredom  in  itself  would  not  be  a  reason  to  recall  a 

patient to hospital.  

  confirmed  that  s.17  leave  would  be  reconsidered  by  the  MDT  on  a 

daily basis and indeed it was in this case.  

In  light  of  the  above,  the  Trust  considers  that  there  had  been  comprehensive 
multi-disciplinary  consideration  of  Daniel’s  case  prior  to  his  s.17  leave  being 
granted which was in line with the Trust policy/procedure in respect of s.17 leave. 
  explained  in  his  evidence  that  once  Daniel  had  started  to  respond  to 
treatment,  his  leave  had  been  progressed  gradually  as  part  of  his  care  and 
treatment plan alongside his depot medication. 
 confirmed that there was 
no  reason  to  suggest  that  the  plan  in  place  was  not  appropriate  and  that  both 
Daniel’s  subjective  and  objective  presentation  were  considered  in  reaching  this 
decision.  To  the  extent  that  there  had  been  any  discrepancy  between  the 
objective  and  subjective  presentation, 
  confirmed  that  the  decision  to 
grant leave would have been reconsidered accordingly.  

In  respect  of  contingency  planning,  Daniel  was  still  detained  under  s.3  of  the 
Mental  Health  Act  at  the  time  of  his  death  and  could  have  been  recalled  to 
hospital in the event that there were any significant concerns raised in respect of 
his mental health whilst on leave. The Trust does not accept that any significant 
concerns  were  raised  which  should  have  triggered  this  recall  and  no  such 
evidence was presented at the inquest hearing. Furthermore, Daniel had agreed 
to engage with treatment in the community and did in fact return to the Shoredrift 
Ward for his depot medication on 2 April 2022. During this appointment, a mental 
state examination was carried out and no issues were raised by Daniel and/or the 
staff  performing  this  examination  (which  included  3  members  of  nursing  staff 
including a clinical lead on the Ward).  

3.  Overall situational awareness about Daniel was not evidenced, including the 

reconciliation of conflicting accounts about him.  

the 

live  evidence  heard  during 

HM  Coroner  is  referred  to  the  response  provided  above  in  respect  of  the 
reconciliation  of  alleged  conflicting accounts about  Daniel’s  presentation.  On  the 
the 
basis  of 
conversations/reviews  by  clinicians  documented  in  Daniel’s  medical  records, 
there  were  no  apparent  conflicting  accounts  of  Daniel’s  mental  health  and 
presentation during his s.17 leave. As set out above, it is accepted that Daniel’s 
mum reported him as being bored and anxious during the leave. It was clear from 
the  evidence  of  the  Trust  and  the  family  that  no  additional  concerns  had  been 
reported in respect of Daniel’s leave. We therefore cannot see that there were any  

inquest  hearing  and 

the 

 
 
  
  
 
 
 
 
 
 
 
 
 conflicting accounts of Daniel’s presentation to be resolved.   

By  way  of  context  and  background,  where  a  patient  does  come  to  harm  after  a 
risk assessment has been carried out and a safety plan put in place, examination 
of  those  circumstances  can  reveal  one  of  three  reasons  as  to  why  the  incident 
has occurred:  

a.  The risk assessment and associated plan may not have been sufficient robust. 
This is the outcome where the Trust endeavours to have the most impact by 
continual  learning,  training  and  practice  improvement.  Whilst  this  is  identified 
as an issue in some incidents that we investigate, it was not the case here. 

b.  The  risk  assessment  and  associated  plan  is  appropriate  to  the  known 
circumstances however an individual has not disclosed their true thoughts and 
intentions  in  the  course  of  the  assessment.  The  Trust  trains  its  clinicians  to 
mitigate  against  this  risk  in  so  far  as  is  possible  but  there  are  limitations  to 
what  can  practically  be  achieved  and  the  subjective  element  of  risk 
assessment  cannot  be  eliminated  completely.  The  risk  assessments  in  this 
case  take  into  account  subjective  and  objective  presentation,  and  collateral 
information from the family during the leave period. As set out above no issues 
were  identified  in  the  in  depth  review  of  this  case  that  suggested  a  lack  of 
clinical curiosity when considering Daniel’s presentation and treatment plan.  

c.  The  risk  assessment  and  associated  plan  is  appropriate,  the  clinician  and 
patient have a full and open discussion about risk and then between the point 
of  the  assessment  and  the  incident,  something  changes  to  escalate  risk  that 
the clinician could not be aware of or have foreseen. Again, there are limits to 
the  extent  to  which  this  can  be  mitigated  against,  however  contingency 
planning to reduce the risk of a repeat self-harm attempt is specifically covered 
in the updated Trust training materials. Contingency and safety planning was 
evident in this case.  

.  
The  Trust’s  position  following  its  own  investigation  and  on  review  of  the  evidence 
given in the proceedings is that this incident falls into the last category. The plan was 
appropriate to the circumstances that were known to the Trust at the time. 

Response  

We hope that the information provided offers you the necessary assurances that the 
Trust already have in place appropriate systems and safeguards to mitigate the risks 
to patients whilst on s.17 leave. The Trust’s policy and associated guidance (attached 
for  your  information)  is  based  on  the  principles  of  current  good  practice  and 
encourages  staff  members  to  exercise  their  clinical  judgement  when  considering 
patient leave as part of a patient’s therapeutic care regime and the management of 
associated  issues  whilst  the  patient  is  on  leave.  As  stated  in  the  response  above, 
there is no reason to suggest that this Policy was not followed in this case and/or that 

 
 
  
  
 
 
 
 
 
 
 
 
 the  Policy  is  not  fit  for  purpose.  Daniel’s  care  and  treatment  was  considered 
appropriately  by  the  professionals  involved  in  his  care  regularly  and  all  decisions 
were made by the multi-disciplinary team.  

In  respect  of  communication  with  carers/family  members,  this  is  a  matter  which  the 
Trust takes very seriously and acknowledges is an important part of patient care and 
treatment.  The  Trust  is  continuously  driving improvement  in  this  area  by  way of  the 
dissemination of lessons learned, training and continuous audit. 

We  also  hope  that  the  above  demonstrates  that  the  Trust  has  invested  time,  effort 
and  resource  into  investigating  the  issues  you  have  highlighted  with  a  view  to 
improving  patient  care  and  safety and  reducing  the  risk of any adverse  incidents or 
outcome  in  the  future.  We  often  find  it  helpful  to  engage  with  Coroners  in  the  local 
area  to  discuss  any  issues  or  concerns  and  would  welcome  a  further  conversation 
with you regarding this matter, should you find it useful to do so.  

Finally,  the  Trust  wishes  to  acknowledge  the  tragedy  that  the  loss  of  Daniel’s  life 
represents  for  his  family  and  friends.  Nothing  within  this  response  is  intended  to 
undermine that acknowledgement.  

Yours Faithfully  

Executive Medical Director and Deputy Chief Executive 
Consultant Forensic Psychiatrist 
Cumbria, Northumberland, Tyne and Wear NHS Trust 
St Nicholas Hospital  
Jubilee Road 
Gosforth 
Newcastle upon Tyne  
NE3 3XT